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Case Reports
. 2020 Mar 1;59(5):657-662.
doi: 10.2169/internalmedicine.3806-19. Epub 2019 Nov 18.

Repeated Perforation of the Gallbladder in a Patient with Hepatocellular Carcinoma Receiving Lenvatinib

Shuya Honda  1 , Yoshinori Saito  1 , Koji Sawada  1   2 , Takumu Hasebe  1   2 , Shunsuke Nakajima  1   2 , Toshikatsu Okumura  2
Affiliations
Case Reports

Repeated Perforation of the Gallbladder in a Patient with Hepatocellular Carcinoma Receiving Lenvatinib

Shuya Honda et al. Intern Med. .

Abstract

A 59-year-old man who was receiving lenvatinib as a third-line tyrosine kinase inhibitor to treat hepatocellular carcinoma and multiple bone metastases complained of general fatigue four months after starting lenvatinib. A blood examination showed unexpectedly elevated serum C-reactive protein (CRP) levels. Computed tomography (CT) revealed rupture of the gallbladder wall, indicating gallbladder perforation. After conservative treatment, the patient received lenvatinib again under informed consent; however, one month later, CT revealed repeated rupture of the gallbladder wall. Gallbladder perforation had again been induced by lenvatinib. For this reason, lenvatinib is strongly considered a causative drug for gallbladder perforation.

Keywords: bone metastasis; gallbladder perforation; hepatocellular carcinoma; lenvatinib.

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Conflict of interest statement

The authors state that they have no Conflict of Interest (COI).

Figures

Figure 1.
Figure 1.
Computed tomography imaging. CT in the arterial (A) and portal (B) phases revealed a small hepatocellular carcinoma at liver segment 8 (arrow). CT: computed tomography
Figure 2.
Figure 2.
Bone metastases of hepatocellular carcinoma. Magnetic resonance imaging revealed metastatic bone tumors at the Th-11 and L-3 vertebrae (arrows) (A), and then a bone biopsy was performed at the L-3 vertebra. Histopathological examinations of the bone biopsy specimens showed a thick trabecular pattern of tumor cells (Hematoxylin and Eosin staining) (B). Immunohistochemical staining was positive for Hep Par 1, suggesting metastatic hepatocellular carcinoma (Hep Par 1) (C).
Figure 3.
Figure 3.
Clinical course. After the administration of LEN, the serum CRP levels suddenly increased. The first gallbladder perforation developed. After resuming LEN, the serum CRP levels increased and the gallbladder perforation was reproduced. SOR: sorafenib, AMI: acute myocardial infarction, REG: regorafenib, LEN: lenvatinib, CRP: C-reactive protein, CT: computed tomography
Figure 4.
Figure 4.
Imaging of the first gallbladder perforation. CT revealed no gallbladder stones or gallbladder metastases of HCC (A). CT showed rupture of the gallbladder wall (arrow) and ascites around the gallbladder, suggesting gallbladder perforation (B). US also indicated rupture of the gallbladder wall (arrow) (C). CT: computed tomography, HCC: hepatocellular carcinoma, US: ultrasonography
Figure 5.
Figure 5.
Imaging of the second gallbladder perforation. CT showed improvement in the gallbladder perforation, but massive ascites remained (A). The 18F-FDG PET/CT findings did not show any FDG uptake in the gallbladder (B). CT and US showed rupture of the gallbladder wall (arrow) (C, D). CT: computed tomography, 18F-FDG PET/CT: 18F-fluorodeoxy glucose-positron emission tomography/computed tomography, US: ultrasonography
See this image and copyright information in PMC

References

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